Access Assessment and Continuity of Care (AAC)

Issue date: 11-01-2022 Issue no: 1

Revision date: 10-01-2023 Revision No. :00
NABH Ref:- Pre Accreditation Entry Level standards for Hospitals- Edition
: 2ND Dec 2014
Document No.: BH/ AAC / 001

AAC 05 – LABORATORY SERVICES ARE PROVIDED AS PER THE SCOPE OF THE HOSPITAL’S SERVICES AND LABORATORY
SAFETY REQUIREMENTS .

1.0 PURPOSE

To provide guidelines for laboratory services as per the requirements of the patients.

2.0 SCOPE

All the patients those who avail laboratory services, the hospital ensures availability of laboratory services
commensurate with the health care service offered

3.0 RESPONSIBILITY

3.1 Laboratory technicians

4.0 ABBREVIATION

4.1 NABH : National Accreditation Board For Hospitals And Healthcare Providers

4.2 AAC : Access, Assessment and Continuity of Care

5. POLICY

5.0 laboratory services are provided at BHATIA HOSPITAL NEURO AND MULTISPECIALITY

5.1Laboratory services are in consonance with the hospital scope of the services:

5.1.1 Biochemistry

5.1.2 Hematology

5.1.3 Pathology

Prepared by : Quality Manager:- MS. REENA Approved by: Managing Director :DR GURJINDER
PAL SINGH
 Access Assessment and Continuity of Care (AAC)
Issue date: 11-01-2022 Issue no: 1
Revision date: 10-01-2023 Revision No. :00
NABH Ref:- Pre Accreditation Entry Level standards for Hospitals- Edition
: 2ND Dec 2014
Document No.: BH/ AAC / 001

-096Microbiology & Serology

The clinical laboratory services sets out the acceptance criteria for samples received to ensure quality and safe
service.

5.2Without written request from the treating doctor, sample shall not be drawn from the patient

5.3Criteria for labeling the samples.

5.4All samples must be labeled with Name of the patient, sex, age, IP.No, date & time of sample taken.

5.5All samples are discarded as per Biomedical Waste Management Handling Rules, 2016.

5.6Turnaround time for each test are defined. Laboratory results are issued within the defined time frame- Critical
results are defined and displayed. Critical results if any are reported to the concerned doctor through
telephone, these are recorded. It is the responsibility of the laboratory staff to communicate any critical test
results to the concerned doctor.

5.7Laboratory personnel are trained in safe practices and are provided with appropriate safety equipment /
devices.

5.8Tests not done in the hospital are outsourced to an approved outside lab. A “Outsourced Test Register” is
maintained with the following details:

5.8.1 Lab. No.,

5.8.2 Age & Sex,

5.8.3 UHID no. /IP No.,

5.8.4 Name of the patient,

5.8.5 Signature of the person sending the sample and receiving the test report.

5.8.6 Test results.

Prepared by : Quality Manager:- MS. REENA Approved by: Managing Director :DR GURJINDER
PAL SINGH
 Access Assessment and Continuity of Care (AAC)
Issue date: 11-01-2022 Issue no: 1
Revision date: 10-01-2023 Revision No. :00
NABH Ref:- Pre Accreditation Entry Level standards for Hospitals- Edition
: 2ND Dec 2014
Document No.: BH/ AAC / 001
y on
collection methods

This policy seeks to describe collection methods for various pathological specimens and to systematize the procurement,
ecord keeping, confidentiality and accountability of specimen drawn at hospital.

General:

1. Proper requisition form is filled by the referring clinician/ RMO / nursing staff. It contains all the information
necessary for performing and interpreting the tests.

2. Sample collection is performed in the ward for indoor patients by nursing staff and in sample collection room
for OPD patients by Lab staff. The details of the procedure are given in primary sample collection manual.

3. The sample is transported to the laboratory within half an hour. Some samples like CSF are transported
immediately. The details are given in primary sample collection manual.

4. At the time of receiving the sample labelling on the vial/ container is matched with the .details mentioned in
the requisition form. In event of doubt or discrepancy, the same is clarified telephonically. If doubt still persists
the sample is not received.

5. After the sample is accepted, a laboratory number is assigned. It is written on the vial as well as the requisition
form.

6. Disposal of samples is done as per the Biomedical Waste Management and Handling Rules.

Procedure for Sample Collection

Outpatients: The treating doctor (consultant /medical officer) of the patient prescribes the investigations to be
performed on OPD slips and fills a laboratory test requisition slips indicating the tests to be performed.
Patient’s / Patient’s attendants are required to take the requisition slip to the OPD Billing counter for the
payment of the charges of the mentioned laboratory test

Prepared by : Quality Manager:- MS. REENA Approved by: Managing Director :DR GURJINDER
PAL SINGH
 Access Assessment and Continuity of Care (AAC)
Issue date: 11-01-2022 Issue no: 1
Revision date: 10-01-2023 Revision No. :00
NABH Ref:- Pre Accreditation Entry Level standards for Hospitals- Edition
: 2ND Dec 2014
Document No.: BH/ AAC / 001
After payment of the charges, where ever applicable, the patients go to the sample collection room in OPD and are
required to produce the payment slip to the lab staff on duty. Patients are asked to wait in queue. However no
number is assigned to the patients and services are provided on the basis of “First come First Serve”, with
exception for serious patients or senior citizens who are given priority. The samples brought from outside the
hospital are submitted to the lab after due payment is made at the common billing counter.

The request for different exams is simultaneously received on the PC in the sample collection room through
Hospital Information System.

The technician verifies the patient’s identification and test request from the bill and the patient. The technician
updates the request i.e.: saves the request. Sample accepting is done to save the patient’s particulars and the
tests requested by him/her, which is a software used in the Laboratory. This system contains all the necessary
information related to the patient provided by the patient at the time of registration. For IPD patients the
request order for test requested are placed by the staff nurse on duty and sample collection in system and
acceptance is done by the lab staff.

The laboratory technicians collect the patient’s sample in the designated sample collection area. The sample is
then collected in the vacutainer which is adequately labelled after following standard sample collection
protocols as defined in the phlebotomy manual (with the patient’s name, UHID, sample type, and date etc.).
Then the samples are stored in laboratory repository. Samples are immediately forwarded to the main
laboratory area for the performance of the designated test.

Test results are verified by pathologist. Test reports with signatures are printed at the respective areas

Inpatients:

The treating doctor of the patient admitted in the inpatient facilities of the hospital prescribes the laboratory test
to be undergone by the patient and indicates the same in the patient case record and fills the laboratory test
requisition form indicating the required laboratory test. The respective patient care area nurse/ member of
medical staff collects the patient’s sample according to the sample collection protocols after properly labelling
the containers. IPD staffs (nurses) who collect the patient sample for investigations are also responsible for
entering the investigation. Samples are brought to the sample collection area in hospital by the ward assistant

Prepared by : Quality Manager:- MS. REENA Approved by: Managing Director :DR GURJINDER
PAL SINGH
 Access Assessment and Continuity of Care (AAC)
Issue date: 11-01-2022 Issue no: 1
Revision date: 10-01-2023 Revision No. :00
NABH Ref:- Pre Accreditation Entry Level standards for Hospitals- Edition
: 2ND Dec 2014
Document No.: BH/ AAC / 001
along with the TRF (test requisition forms) which contain all the necessary information about the sample i.e.:
patient name, UHID, date name or the investigation to be performed, name of the staff sending the samples
etc. Samples are forwarded to the laboratory immediately.

Identification, Handling and Transportation of Samples

All samples are appropriately labelled with the patient’s name, UHID no., date etc which facilitates its proper
identification. Samples not properly labelled are rejected by the laboratory and are returned to the respective
sample collection area of the hospital.

Proper precautions are taken for collecting and handling of samples and care is taken for maintenance of aseptic
conditions. It is mandatory for the staff members to wear appropriate personal protective equipment’s while
handling the samples. The wearing of latex sterile gloves is mandatory during phlebotomies and the gloves are
changed SOS when ever soiled / spotted with blood.

Transportation of samples from the various patient care areas of the hospital to the laboratory is done in
appropriate leak proof containers so as to prevent any form of spillage.

In the laboratory each sample is assigned a specific lab number which is generated (hard copy), and entered in the
laboratory register for facilitating segregation of samples and record keeping.

6.0 REFERENCE

Pre Accreditation Entry Level standards for Hospitals-Second Edition: Dec 2014

Prepared by : Quality Manager:- MS. REENA Approved by: Managing Director :DR GURJINDER
PAL SINGH